This cohort study assesses the association of early initiation of weight-bearing after fibula free flap surgery with donor-site complications, length of stay, and discharge to home status.
Key Points
Question
Is early weight-bearing associated with improved postoperative recovery following fibula free flap surgery?
Findings
In this cohort study of 152 patients who underwent fibula free flap surgery, early initiation of weight-bearing on postoperative day 1 was associated with a reduction in donor-site complications and shorter length of stay and an increase in the rate of discharge to home. Conversely, delayed initiation of weight-bearing was associated with increased risk of pneumonia.
Meaning
Early weight-bearing initiation after fibula free flap surgery is associated with improved postsurgical recovery.
Abstract
Importance
Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery.
Objective
To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status.
Design, Setting, and Participants
This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included.
Exposure
EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later.
Main Outcomes and Measures
Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups.
Results
A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99).
Conclusions and Relevance
In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.
Introduction
Early postoperative ambulation is a major component of Enhanced Recovery After Surgery (ERAS), and evidence has shown in multiple surgical fields that early ambulation is associated with a reduced risk of complications and reduced length of stay.1,2,3 In 2017, ERAS guidelines recommended early mobilization within the first 24 hours after major head and neck surgery with free flap reconstruction but noted limited data specific to head and neck surgery.4 There remains a gap in understanding how early mobilization affects postoperative recovery in head and neck reconstructive surgery.
The fibula free flap (FFF) is a workhorse flap used for osseous reconstruction in head and neck surgery because of its advantages of the long pedicle length, length of bone stock, and low donor-site morbidity.5,6,7 Despite its widespread use, to our knowledge there are no studies assessing if early weight-bearing (EWB) after head and neck free flap surgery using the FFF affects postoperative recovery. The timing of weight-bearing initiation following FFF surgery varies substantially across institutions and is based on surgeon preferences, ranging from within 24 hours after surgery to 7 days postoperatively.7,8,9 Therefore, it is important to understand the safety of EWB in these patients and whether it could improve postoperative recovery. The objective of this cohort study was to assess the association of EWB after FFF surgery with postoperative recovery, as assessed by donor-site complications, postoperative complications such as pneumonia, hospital length of stay, and discharge disposition.
Methods
Patient Selection and Outcome Measures
The protocol was approved and a waiver for informed consent from participants was obtained by the Mass General Brigham Institutional Review Board prior to data collection. The medical records of all patients who underwent head and neck reconstruction using a FFF at Massachusetts Eye and Ear were retrospectively reviewed. Patients were included in the study if they received fibula osteocutaneous free flap reconstruction between January 11, 2010, and August 11, 2022, and had a documented date of postoperative weight-bearing initiation.
Demographic and treatment information was obtained for each patient, including baseline descriptive information (age, sex, patient-reported race and ethnicity [including Asian, Black, White, and other], and smoking status), comorbidities, indication for surgery, surgical details (total procedure time; free flap ischemia time; donor-site laterality, closure, and dressing; tracheostomy placement; and positive margin status), and documentation of when the patient started at least partial weight-bearing (weight-bearing <50% of body weight). Race and ethnicity were collected because prior studies have shown presence of racial and ethnic disparities in outcomes for patients with head and neck cancer.10,11 Donor-site closure method included primary closure and skin graft, and donor-site dressings included negative-pressure vacuum-assisted closure, cast, or elastic bandage wrap (ACE) only. Comorbidities recorded included history of peripheral vascular disease, other cancer, coronary artery disease, hypercoagulable disease, diabetes, stroke, and respiratory disease. Outcome measures, including early donor-site complications, pneumonia, length of stay, and discharge disposition, were recorded for each patient.
Statistical Analysis
Baseline and surgical characteristics of the study sample were assessed with descriptive analyses. For the primary analysis, we assessed whether the timing of initiation of weight-bearing after surgery was associated with differences in the following outcomes: (1) postoperative donor-site complications (surgical-site infections, dehiscence, deep vein thrombosis, and venous congestion), (2) pneumonia, (3) hospital length of stay, and (4) discharge to home. Patients were divided into EWB vs non-EWB groups. EWB was defined as ambulation on postoperative day (POD) 1, and delayed weight-bearing (non-EWB) was defined as ambulation on POD 3 or later. The outcomes for the EWB group were compared with those of all other patients by calculating odds ratios (ORs) and 95% CIs using univariate logistic regression.
For the secondary analysis, we assessed whether any patient variables, including time of weight-bearing initiation, were associated with improved postoperative recovery (postoperative donor-site complications, pneumonia, hospital length of stay, and discharge to home) using multivariate logistic regression. Adjusted ORs (AORs) were calculated with adjustment for age, sex, and other comorbidities using multivariate logistic regression. Furthermore, additional analyses were performed to assess whether surgical characteristics, such as donor-site closure, were associated with improved postoperative recovery using univariate regression. Variables that were significant in the univariate regression were incorporated into the multivariate logistic regression for further analysis.
Variables with fewer than 5 patients in either the EWB or non-EWB group were excluded in the regression analyses due to the limited number of patients. A 2-sided P < .05 was considered to be statistically significant. All analyses were performed using R, version 4.2.2, and RStudio, version 2022.07.2 + 576 (R Foundation for Statistical Computing).
Results
Patient Characteristics
Baseline characteristics were determined for 152 patients (Table 1). There were 55 patients who were in the EWB group. The most common indication for surgery was head and neck cancer (126 [82.9%]), followed by osteoradionecrosis of the mandible (20 [13.2%]). A total of 6 patients presented with other indications, which included reconstruction of the mandibular defect due to a gunshot wound (n = 3), odontogenic keratocyst (n = 1), mucor infection (n = 1), and reconstruction for C-spine stabilization (n = 1). There was a statistically significant larger proportion of patients in the EWB group with these other indications for surgery, although the comparison was limited due to the small number of these patients with other indications (5 of 55 [9.1%] in the EWB group and 1 of 97 [1.0%] in the non-EWB group; difference, 8.1 percentage points [pp]; 95% CI, 1.2-18.6 pp). All other baseline characteristics between the 2 groups were not different in any clinically meaningful way.
Table 1. Baseline Characteristics.
| Characteristic | No. (%) | ||
|---|---|---|---|
| All patients (N = 152) | EWB group (n = 55) | Non-EWB group (n = 97) | |
| Age at surgery, median (IQR), y | 63 (55-70) | 63 (55-70) | 63 (56-70) |
| Sex | |||
| Female | 63 (41.4) | 22 (40.0) | 41 (42.3) |
| Male | 89 (58.6) | 33 (60.0) | 56 (57.7) |
| Race and ethnicitya | |||
| Asian | 9 (5.9) | 1 (1.8) | 8 (8.2) |
| Black | 4 (2.6) | 3 (5.5) | 1 (1.0) |
| White | 135 (88.8) | 49 (89.1) | 86 (88.7) |
| Other | 4 (2.6) | 2 (3.6) | 2 (2.1) |
| Comorbidity | |||
| Peripheral vascular disease | 2 (1.3) | 1 (1.8) | 1 (1.0) |
| Other cancer | 10 (6.6) | 5 (9.1) | 5 (5.2) |
| Coronary artery disease | 9 (5.9) | 3 (5.5) | 6 (6.2) |
| Hypercoagulable disease | 1 (0.7) | 0 | 1 (1.0) |
| Diabetes | 21 (13.8) | 8 (14.5) | 13 (13.4) |
| Stroke | 2 (1.3) | 2 (3.6) | 0 |
| Respiratory disease | 9 (5.9) | 2 (3.6) | 7 (7.2) |
| Prior fibula free flap surgery | 8 (5.3) | 4 (7.3) | 4 (4.1) |
| Surgery indication | |||
| Head and neck cancer | 126 (82.9) | 42 (76.4) | 84 (86.6) |
| Osteoradionecrosis | 20 (13.2) | 8 (14.5) | 12 (12.4) |
| Otherb | 6 (3.9) | 5 (9.1) | 1 (1.0) |
| Salvage surgery | 41 (27.0) | 11 (20.0) | 30 (30.9) |
| Smoking status | |||
| Never | 56 (36.8) | 25 (45.5) | 31 (32.0) |
| Former | 73 (48.0) | 22 (40.0) | 51 (52.6) |
| Current | 23 (15.1) | 8 (14.5) | 15 (15.5) |
Abbreviation: EWB, early weight-bearing.
Race and ethnicity were reported by the patient, including other, which was not further specified.
Other includes reconstruction of the mandibular defect due to a gunshot wound (n = 3), odontogenic keratocyst (n = 1), mucor infection (n = 1), and reconstruction for C-spine stabilization (n = 1).
Surgical characteristics were also determined for the patients (Table 2). Patients in the EWB group had a much larger proportion of donor-site dressing with elastic bandage wrap only compared with the non-EWB group (38 of 55 [69.1%] vs 3 of 97 [3.1%]; difference, 66.0 pp; 95% CI, 51.7-76.8 pp) and with less proportion of donor-site dressing with a cast (17 of 55 [30.9%] vs 90 of 97 [92.8%]; difference, 61.9 pp; 95% CI, 47.0-73.1 pp). There were no clinically meaningful differences between the 2 groups in any of the other surgical characteristics, including median total procedure time, median flap ischemia time, donor-site closure method, donor-site laterality, tracheostomy placement, and positive margin status.
Table 2. Surgical Characteristics.
| Characteristic | No. (%) | ||
|---|---|---|---|
| All patients (N = 152) | EWB group (n = 55) | Non-EWB group (n = 97) | |
| Total procedure time, median (IQR), min | 531 (472-580) | 542 (460-584) | 528 (482-552) |
| Free flap ischemia time, median (IQR), min | 138 (114-168) | 128 (104-155) | 146 (120-170) |
| Donor-site closure | |||
| Primary | 129 (84.9) | 45 (81.8) | 79 (81.4) |
| Skin graft | 23 (15.1) | 7 (12.7) | 16 (16.5) |
| Donor-site dressing | |||
| Elastic bandage wrap only | 41 (27.0) | 38 (69.1) | 3 (3.1) |
| Negative-pressure vacuum-assisted closure | 4 (2.6) | 0 | 4 (4.1) |
| Cast | 107 (70.4) | 17 (30.9) | 90 (92.8) |
| Donor-site laterality, left | 83 (54.6) | 32 (58.2) | 51 (52.6) |
| Tracheostomy placement | 144 (94.7) | 51 (92.7) | 93 (95.9) |
| Positive margins | 13 (8.6) | 5 (9.1) | 8 (8.3) |
| Postoperative weight-bearing, median (IQR), d | 3 (1-5) | 1 (1-1) | 5 (3-5) |
Abbreviation: EWB, early weight-bearing.
Association of EWB With Postoperative Outcomes
In the descriptive analysis, a total of 14 patients (9.2%) had donor-site complications, with a much smaller proportion of patients experiencing similar complications in the EWB group than in the non-EWB group (1 of 55 [1.8%] vs 13 of 97 [13.4%]; difference, 11.6 pp; 95% CI, 2.1-19.9 pp; Table 3). The most common donor-site complication was infection (11 [7.2%]), followed by deep vein thrombosis (2 [1.3%]) and venous congestion (1 [0.7%]). The mean (range) length of stay for all patients was 11.8 (5-32) days postoperatively, with the majority of patients (n = 119 [78.3%]) discharged to home. The EWB group had shorter overall length of stay, with a mean (range) length of stay of 10.4 (5-31) days compared with 12.6 (5-32) days in the non-EWB group (difference, 2.2 days; 95% CI, 0.5-4.0 days). The EWB group also had a greater rate of discharge to home compared with the non-EWB group (51 of 55 [92.7%] vs 68 of 97 [70.1%]; difference, 22.6 pp; 95% CI, 9.8-35.5 pp).
Table 3. Surgical Outcomes.
| Characteristic | No. (%) | ||
|---|---|---|---|
| All patients (N = 152) | EWB group (n = 55) | Non-EWB group (n = 97) | |
| Donor-site complications | 14 (9.2) | 1 (1.8) | 13 (13.4) |
| Venous congestion | 1 (0.7) | 0 | 1 (1.0) |
| Infection | 11 (7.2) | 1 (1.8) | 10 (10.3) |
| Deep vein thrombosis | 2 (1.3) | 0 | 2 (2.1) |
| Length of stay, mean (range), d | 11.8 (5-32) | 10.4 (5-31) | 12.6 (5-32) |
| Discharge to home | 119 (78.3) | 51 (92.7) | 68 (70.1) |
| Pneumonia | 13 (8.6) | 2 (3.6) | 11 (11.3) |
Abbreviation: EWB, early weight-bearing.
Logistic analyses similarly demonstrated that EWB was associated with improved surgical outcomes (Table 4 and eTable 1 in Supplement 1). After adjusting for age, sex, race and ethnicity, and comorbidities, EWB was associated with a large reduction in donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94) and length of stay (AOR, 0.10; 95% CI, 0.02-0.60; eFigure in Supplement 1). EWB was also associated with a higher rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80). EWB was associated with a large reduction in the risk of pneumonia in the adjusted analysis (AOR, 0.29; 95% CI, 0.06-1.44). Delayed weight-bearing on POD 3 or later was associated with a higher risk of postoperative pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). For all analyses, the large width of the 95% CIs prevents making definitive conclusion about the magnitude of the true risk.
Table 4. Multivariate Regression Analysis of Postsurgical Outcomes.
| Variable | Adjusted odds ratio (95% CI) | |||
|---|---|---|---|---|
| Donor-site complications | Length of stay | Discharge to home | Pneumonia | |
| Age at surgery | 1.03 (0.97-1.09) | 1.05 (0.99-1.13) | 0.92 (0.87-0.96) | 1.08 (1.00-1.16) |
| Female sex | 0.34 (0.08-1.45) | 0.19 (0.03-1.05) | 1.03 (0.42-2.52) | 0.41 (0.1-1.73) |
| White race | 3.63 (0.32-40.71) | 4.09 (0.25-67.00) | 0.33 (0.06-1.85) | 2.50 (0.22-28.15) |
| Comorbidity | ||||
| Other cancer | 1.80 (0.16-20.75) | 1.34 (0.04-42.57) | 1.39 (0.24-8.05) | NA |
| Diabetes | 0.32 (0.03-2.92) | 1.08 (0.09-12.63) | 2.13 (0.52-8.68) | 0.39 (0.04-3.44) |
| Smoking status | ||||
| Former | 4.84 (0.56-41.92) | 0.90 (0.13-6.12) | 1.27 (0.48-3.38) | 3.21 (0.58-17.76) |
| Current | 21.36 (1.91-239.38) | 8.17 (0.6-112.00) | 0.53 (0.14-2.09) | 10.04 (1.11-90.96) |
| Early weight-bearing | 0.11 (0.01-0.94) | 0.10 (0.02-0.60) | 7.43 (2.23-24.80) | 0.29 (0.06-1.44) |
| Delayed weight-bearing | NA | NA | NA | 6.82 (1.33-34.99) |
Abbreviation: NA, not applicable.
Association of Patient and Surgical Characteristics With Postoperative Outcomes
Other patient characteristics, such as current smoking status, were associated with postsurgical outcomes. Multivariate logistic regression showed that current smoking status was associated with increased donor-site complications (AOR, 15.28; 95% CI, 1.67-139.52) and risk of pneumonia (AOR, 10.04; 95% CI, 1.11-90.96) but was not associated with length of stay or discharge to home status, although the large 95% CIs prevent making a definitive conclusion about the magnitude of the true effect. There was a smaller association of increased age with decreased discharge to home (AOR, 0.92; 95% CI, 0.87-0.96) and increased risk of pneumonia (AOR, 1.08; 95% CI, 1.00-1.16).
Surgical characteristics such as total procedure time, total free flap ischemia time, donor-site laterality, and positive margin status were not associated with the postsurgical outcome measures in a clinically meaningful or consistent way (eTable 2 in Supplement 1). In univariate analysis, donor-site dressing with a cast was associated with increased length of stay (OR, 12.95; 95% CI, 1.90-88.32) and decreased discharge to home (OR, 0.13; 95% CI, 0.03-0.58). However, since dressing with a cast was considerably greater in the non-EWB group, multivariate regression adjusting for EWB status was not performed. After adjusting for age, sex, race and ethnicity, comorbidities, smoking status, and EWB status, donor-site closure with skin graft was not associated with donor-site complications (eTable 3 in Supplement 1).
Discussion
Although the FFF is widely used for head and neck reconstructive surgery, there is a paucity of data to support decisions regarding the timing of weight-bearing after surgery. The present results suggest that EWB following FFF improves postoperative recovery, including decreased risk of donor-site complications, shorter length of stay, and increased discharge to home. Conversely, delayed weight-bearing was associated with higher risk of pneumonia.
EWB facilitates early mobilization, which is an important component of ERAS pathways. Early mobilization is associated with reduced risk of complications and hospital length of stay in various surgical disciplines.1,2,3,12,13 These findings have also been demonstrated in general head and neck reconstructive surgery. In a randomized trial by Yang et al,14 in patients with head and neck surgery with free flap reconstruction, weight-bearing on POD 3 was associated with reduced urinary catheter and nasogastric tube removal time and improved patient comfort levels compared with the group with delayed weight-bearing on POD 6. In a retrospective study by Yeung et al,15 delayed weight-bearing after POD 4 increased risk of pneumonia in patients who underwent free flap reconstruction. In a study by Twomey et al,9 early mobilization within 24 hours following head and neck surgery with free flap reconstruction was associated with decreased postoperative complications, and mobilization after POD 2 was associated with a prolonged length of stay and an increased risk of pneumonia. While these studies included all free flap reconstructive surgeries, we focused specifically on FFF surgery because weight-bearing and ambulation have traditionally been avoided in the immediate postoperative setting due to concerns over donor-site complications.16 We also broadened the analysis to include hospital disposition location as a surrogate for postsurgical functional recovery. Taken together with prior evidence, this study supports that EWB on POD 1 following FFF surgery can enhance postsurgical recovery.
EWB could also enhance postoperative recovery due to improved healing response at a more molecular level. In patients with Achilles tendon rupture, EWB mobilization induced upregulation of glutamate, a metabolite that is involved in epidermal and bone healing.17 At the cellular level, mechanical loading has been shown to induce changes in the bone matrix that are sensed by osteocytes, leading to increased bone remodeling.18,19 Animal studies have suggested that weight-bearing increases bone formation through alterations in BMP 2/4 expression and collagen type I and II expression.20 Furthermore, numerical models of fracture healing have shown that moderate early loading after fractures leads to increased callus formation and shorter time to union compared with delayed loading.21 These cellular and molecular mechanisms may contribute to improved healing in patients following FFF surgery as well.
In this study, overall perioperative donor-site complication occurred in 9.2% of patients, which is in the range of previously reported complication rates.7,8 Factors associated with increased donor-site complication included weight-bearing after POD 1 and current smoking status. Smoking has been associated with increased complication rates in head and neck surgery in prior studies.7,22,23 Taken together with existing literature, this study suggests that cessation of smoking and early ambulation could lead to reduced donor-site complication after FFF surgery.
Limitations
There were limitations to this study. This study is retrospective and from a single institution. It is also limited due to the small number of outcome events, thus leading to imprecision of the effect size estimates, demonstrated by the wide 95% CIs. Additionally, the implementation of EWB started in 2016, with EWB comprising the majority of cases by 2019. While there were no other identifiable changes in process measures that occurred during that time, there could be potential additional confounders that led to the improved postoperative outcomes.
This study, in analyzing donor-site complications, recorded perioperative donor-site complications. Future studies could include long-term complications such as chronic paresthesia and chronic pain. Also, we assigned the first day of weight-bearing as the first day that the patient had partial or full weight. Further analysis could include more patient comorbidities and surgical characteristics, and whether partial weight-bearing prior to full weight-bearing affects postsurgical recovery. Future research would also assess the effect of EWB on the cost, pain, and need for physical therapy. Nevertheless, this work highlights the importance of early ambulation after FFF surgery for improved recovery.
Conclusions
In this cohort study, EWB following FFF surgery was associated with improved postsurgical recovery. Initiation of weight-bearing on POD 1 was associated with decreased risk for perioperative donor-site complications, shorter length of stay, and improved functional recovery as assessed by discharge to home status. Initiation of weight-bearing on POD 3 or after was associated with increased risk of pneumonia.
eTable 1. Univariate Regression Analysis of Post-Surgical Outcomes
eTable 2. Univariate Regression Analysis of Surgical Characteristics and Post-Surgical Outcomes
eTable 3. Multivariate Regression Analysis of Surgical Characteristics and Donor Site Complications
eFigure. Distribution of Hospital Length of Stay in EWB and non-EWB patient groups
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eTable 1. Univariate Regression Analysis of Post-Surgical Outcomes
eTable 2. Univariate Regression Analysis of Surgical Characteristics and Post-Surgical Outcomes
eTable 3. Multivariate Regression Analysis of Surgical Characteristics and Donor Site Complications
eFigure. Distribution of Hospital Length of Stay in EWB and non-EWB patient groups
Data Sharing Statement